"All illness is psychosomatic," says Dr. Stephen A. Green, even if there are "a lot of patients, a lot of doctors and a lot of nurses out there who still don't understand that."
Psychosomatic, says Green, "used to mean that someone had an emotional problem that caused some type of illness, and that just isn't what it is."
Now the phrase refers to any interaction of body and mind. Sometimes emotions, through their neurobiological influence on brain chemicals and the immune system, can make the body more vulnerable to disease. And often diseases -- from the flu to a heart attack -- can cause serious emotional reactions. Mind and body can continue to interact -- emotions on disease process, disease on emotions -- affecting the course and outcome of the illness.
Green is a professor of psychiatry at Georgetown University Medical Center where he won the Golden Apple, a coveted award voted by medical students, and author of "Mind and Body: The Psychology of Physical Illness" (American Psychiatric Press Inc., $22.50) He sees his mission -- as teacher, writer, therapist -- as one to convince public and health-care givers alike of the basic and ineluctable interrelationship of body and mind.
And despite the growing scientific evidence linking emotions to changes in brain chemistry and, in turn, to changes in body chemistry, there remains a kind of blindness, almost a prejudice against the suggestion that emotions play a role in the disease process. People hear only the old, outmoded definition of psychosomatic that "it's all in your head" (that is, it's imaginary) or that psychosomatic means only that the illness was brought on by emotions.
"In extreme cases," says Green, "the interaction between mind and body is easier to understand. If someone, tragically, has an amputation, then everyone -- patients, families, physicians and nurses -- all realize that the patient is going to have a lot of feelings about that, and they act accordingly. But that can also apply to someone who's got a chronic ulcer, or migraine headaches."
People have to realize, he says, that "if somebody gets sick, although you can more easily see the effects of that illness on an individual's body, there are also effects that take place in their emotional lives which can be seen if you are taught to look for them. So I think when patients are being treated, just as a physician listens for a heart murmur, he should listen for clues to the patient's emotional state."
"A physical illness can cause a feeling which can then aggravate physical illness which can then aggravate the feeling and it can go around and around and around." Depending on how the body and the brain interact, emotions can make the physical illness better or worse.
Part of the problem, says Green, who graduated from Harvard College and from the State University of New York Downstate Medical Center, at least from the viewpoint of the physician, "is that from day one in my medical school training, I was taught in a very compartmentalized way. You learn anatomy, biochemistry, surgery, pediatrics, and I got to learn that an illness was an organic pathology -- a bad liver, a bad kidney, a bad heart. That's just the way I was taught and that feeds on itself."
Newer medical specialities such as adolescent medicine or family medicine are a step away from such compartmentalization. "Still," says Green, "we work in a very highly specialized technical world of medicine where, although I think patients can get excellent technical care, the total patient can get lost in that world."
As a medical intern, Green was disillusioned and "infuriated" at what he saw as a common scenario. "Most patients initially received sympathetic and encouraging support from medical personnel -- often perfunctory, but genuinely motivated. However, if the patient stagnated clinically, a remarkable transformation occurred. He or she was progressively depersonalized by caretakers, who came to regard the patient more as an intellectual challenge and less as a human being."
Now, as a model for teaching the very philosophy he missed during his own training years, Green likes to use the example of a heart patient:
This is what happens after a heart attack, Green says: "There is an initial period when most people deny its significance. Then they get real anxious, and that anxiety, aside from making them feel bad, can also cause their hearts to beat more irregularly. That makes them more anxious and just paying attention to the heart, just treating the organ, doesn't really take care of the patient."
Not all of the interactions are so easily described or detected, but Green feels it is crucial that they be addressed. Indeed, he says his favorite quote from the book is this: "Medical illness produces emotional responses which are an integral part of the disease process, and medical personnel who ignore these psychological reactions provide sub-optimal, if not detrimental, treatment."
There is plenty of scientific data, in addition to the new frontiers being explored in fields such as psychoneuroimmunology, that shows emotions and subjective perceptions can be directly linked to weaknesses and strengths in the body's immune system.
For one thing, says Green, "there is data on depressed individuals who undergo surgery versus people who are not depressed and have surgery. Those who are not depressed have much less morbidity sickness and mortality. You can't really explain that physiologically, but it is a fact. And there are a lot of facts like that."
It is Green's basic position that all physicians, nurses and other healthcare workers should be alert for anxieties, depressions, rages that can accompany, exacerbate or somehow grow out of even the smallest illness. Often, he believes, these can be discussed, eventually handled without necessity for psychiatric intervention -- by caring and empathic caregivers who have been taught a little more than the symptoms of a bad liver.
But he agrees as well with psychiatric colleagues who are carving out a sub-specialty known as consultation-liaison psychiatry, devised specifically to enhance the healing process by tamping an illness's attendant emotions.
Both the kind of attention Green would like to see bestowed by health personnel on patients and the kind of expertise brought by the consulting psychiatrist have been shown to be cost effective.
Yet both are, in many cases, threatened by technological and bottom-line medical practice.
The American Psychiatric Association has published a number of studies attesting to the cost effectiveness of mental health intervention in physical illness. For example, two psychiatrists in New York -- Drs. Stephan J. Levitan and Donald S. Kornfeld -- studied a group of elderly women in the orthopedic ward of a New York hospital. All of the women had undergone surgery for fractured femurs -- the bone that extends from the hip to the knee. The two psychiatrists found that members of the group in which a liaison psychiatrist participated in the postoperative care were able to leave the hospital an average of 12 days sooner than the other women. Twice as many patients in the group with psychiatric participation were able to return home, rather than going to a nursing home.
Nevertheless, Dr. Steven Sharfstein, deputy medical director of the American Psychiatric Association, recently wrote in an introduction to an article in the journal Hospital and Community Psychiatry: "In this era of prospective payment and efforts to contain medical care costs through increased efficiency, consultation-liaison psychiatry has high promise as one of the more cost-effective tools to reduce expensive hospital care. It is, however, one of the least reimbursed services in the hospital today."
And Green agrees that emphasis on numbers of patients seen in an hour, found often in burgeoning health maintenance organizations, can obstruct the interaction between doctor and patient necessary for the detection of emotional issues. "It's not an ideal world," he says, "and I don't have a perfect answer, but you can ask a medical patient about his emotional past, and that might give you a clue to how they might react to whatever physical illness they have. Thirty years ago you didn't ask about sex with patients. Now you do. So you can ask about their emotions, too."